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Despite a lack of clinical trial data, β-blockers are widely prescribed to dialysis patients. There is considerable heterogeneity among β-blocker medications in terms of key pharmacologic variables such as cardioselectivity and dialyzability. While the majority of existing evidence indicates a survival benefit with β-blocker use in dialysis patients, the optimal β-blocker agent for this population remains uncertain.
We analyzed data from a large international cohort study of 58,338 patients on maintenance hemodialysis across 18 countries who were prescribed a β-blocker medication within the Dialysis Outcomes and Practice Patterns Study (DOPPS). The following β-blocker agents were compared: metoprolol, atenolol, bisoprolol, carvedilol, and labetalol. Employing an ‘intention to treat’ study design, multivariable Cox proportional hazards models which accounted for patient-based and dialysis-specific factors were used to estimate the associations between individual β-blocker agents prescribed and all-cause mortality. Stratified analyses were performed on patients with and without a prior history of cardiovascular disease. A sensitivity analysis employing an ‘as treated’ study design was also performed.
The mean (SD) age was 63 (15) years of the cohort and 59% of participants were male. The most commonly prescribed β-blocker agent was metoprolol (46%) followed by carvedilol (28%), atenolol (11%), bisoprolol (9%), and labetalol (7%). The crude and adjusted hazard ratios (HR) for all-cause mortality by β-blocker agent are displayed in the attached Figure. Compared to metoprolol, atenolol (adjusted HR 0.83 [95%CI 0.75-0.91]) and bisoprolol (adjusted HR 0.79 [95%CI 0.67-0.93]) were associated with lower mortality risk. There was no difference in mortality risk with carvedilol (adjusted HR 0.99 [95%CI 0.86-1.15]) but an increased mortality risk with labetalol (adjusted HR 1.07 [95%CI 1.02-1.12]) compared to metoprolol. These results were consistent upon stratification of patients by presence or absence of a prior history of cardiovascular disease. A sensitivity analysis employing an ‘as treated’ study design also yielded similar results.
In a large international cohort of maintenance hemodialysis patients prescribed β-blocker medications, atenolol and bisoprolol (both of which are cardioselective and moderately-to-highly dialyzable agents) were associated with the lowest mortality risk compared to alternative agents. This was true for both patients with and without a prior history of cardiovascular disease. These findings will serve to inform clinicians on β-blocker selection for the hemodialysis patient population.